The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term care and ancillary, DME or medical services.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conducts retrospective claims review, either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager UM.
- Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies and procedures for each product line.
- Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients.
- Documents and maintains patient-specific utilization management records in database and files.
- Assists in the refinement/improvement of the HS programs. Participates in continuous process improvement endeavors.
- Works with other PHC departments to resolve issues relating to authorization of medical services.
- Audits medical records as appropriate.
- Performs inter-rater reliability audits as directed by department manager.
- Elicits medical information from providers and medical records and applies clinical judgement to determine medical necessity and provide timely reports/authorizations for recommended treatment.
- Refers cases that do not meet criteria on to the PHC HS department manager, director or Chief Medical Officer as appropriate.
SECONDARY DUTIES AND RESPONSIBILITIES
- Participates in special projects and assignments as required.
Education and Experience
LVN with 2-3 years experience to include one (1) year managed care (utilization management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in UM preferred.
Special Skills, Licenses and Certifications
Current California LVN license; valid California driver’s license. Strong knowledge nursing requirements in a clinical setting. Knowledge of utilization management programs as related to use of pre-set criteria and protocols. Familiarity with business practices and protocols with ability to access data and information using automated systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required.
Performance Based Competencies
Excellent written/verbal communication skills with ability to read and interpret benefit contract specifications. Ability to understand and follow established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply clinical judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.
Work Environment And Physical Demands
Daily use of telephone and computer for most of the day. Cubicle work station. Ability to use a PC keyboard. Must be able to lift, move or carry objects of varying size weighing up to 10 lbs. Must be able to operate a vehicle used for company business. Daily use of telephone and computer for most of the day.
All Healthplan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the Healthplan’s policies and procedures as they may from time to time be updated.
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
Partnership HealthPlan of California - 4 months ago